73. Palliative Care (40%) Flashcards
Chez tous les patients atteints de maladie en phase terminale (p. ex. insuffisance cardiaque congestive ou néphropathie au stade terminal), faites appel aux principes des soins palliatifs pour soulager les symptômes (c.-à-d. ne limitez pas le recours aux soins palliatifs uniquement aux cancéreux).
Chez les patients qui nécessitent des soins palliatifs, offrez quoi?
- votre soutien personnel
- l’expertise des autres disciplines
- l’accès aux ressources communautaires, en fonction des besoins du patient
- (c.-à-d. utilisez une approche multidisciplinaire lorsque nécessaire).
Chez les patients en fin de vie,
* a) Identifiez les éléments qui sont importants pour le patient, en incluant les aspects physiques (p. ex., dyspnée, douleur, constipation, nausées), les aspects émotionnels, les aspects sociaux (p. ex. tutelle, testament, finances) et les aspects spirituels.
* b) Intéressez-vous aux questions importantes du patient.
Chez les patients aux prises avec des douleurs, traitez-les efficacement (p. ex., ajustez les posologies, changez d’analgésiques) :
* par des réévaluations fréquentes ;
* en surveillant les effets indésirables des médicaments (p. ex. nausées, constipation, atteinte cognitive).
Lorsqu’on a posé un diagnostic de maladie terminale, identifiez et clarifiez régulièrement les volontés de fin de vie du patient (p. ex., souhaits concernant le traitement des infections, l’intubation, fin de vie à domicile).
Name common concerns in palliative care
- Dyspnée
- Nausée
- Constipation
- Douleur
- Polypharmacie
Nommez les 6 complications en soins pall à savoir
- Hypercalcémie
- Saignement massif
- Crise épileptique
- Obstruction de la veine cave supérieure
- Compression moelle épinière
- Toxicité aux opioïdes
Describe management : Hypercalcémie
- Hydrate
- Biphosphonate
- Calcitonine / stéroïdes
Describe management : Massive bleed
Kit de saignement : serviettes foncées, Versed (benzo)
Describe management : Seizure
Benzo ou phénobarbital (barbiturique, anticonvulsivant)
Describe management : Obstruction de la veine cave supérieure
- Poumon, lymphomes non hodgkiniens
- Traitement: Surélévation de la tête, dexaméthasone, opioïde, benzodiazépines pour la dyspnée
- Stent vs chimio/radiothérapie
Describe management : Compression moelle
- Prostate, sein, poumon
- Dexaméthasone
- Radiation/chirurgie
Describe management : Opioid toxicity
- Hydrate
- Rotate
- Tx symptoms
Describe : Principles of Palliative Care (9)
- Affirms life and regards dying as a normal process
- Neither hastens nor postpones death
- Provides relief from pain and other distressing symptoms
- Integrates the spiritual, cultural, psychosocial aspects of care
- Ask patients about meaning of symptom/burden
- Patient, family, caregivers are treated with dignity and respect
- Patient, family, caregivers are supported in bereavement
- Offers a support system to help patients live as actively as possible until death
- Offers a support system to help patients’ families cope during the patient’s illness and in their own bereavement
Describe management of Massive Hemorrhage in palliative care
- Anticipation (head and neck tumors - carotid, lung, GI, hematological)
- Prepare the entourage
- Major distress order (see below)
- Cover with dark blankets/towels
- Consider tranexamic acid
Describe management of dyspnea in palliative care (4)
- Position (turn, sit up, elevate head of bed)
- Air circulation (fan), oxygen PRN
- Manage cough, secretions, anxiety (relaxation therapy)
- Opioids (eg. morphine 1mg PO), benzodiazepines, bronchodilators
Describe management of pain in palliative care (4)
- Total Pain (physical, psychological, social, spiritual)
- Non-Pharmacological
- Opioids (eg. morphine liquid or subcutaneously)
- Adjuvant: Acetaminophen, NSAIDs, steroids, bisphophonates, cannabinoids
- Interventional techniques (nerve block)
- Frequent reassessments
Name : Risk factors for difficult pain control (6)
- Rapid titration of opioids
- Addiction or chemical coping
- Psychiatric
- Incidental
- Delirium
- Neuropathic pain (DN4)
Describe tx : Neuropathic pain
- Gabapentinoids
- TCA
- SNRI
- opioids
- cannabinoids
- methadone
- Topical lidocaine, capsaicin
Name Non-Pharmacological management for pain (6)
- Massage / Physical therapy
- Pet therapy
- Acupuncture
- Relaxation / Hypnotherapy
- Aromatherapy / Music therapy
- Heat/Cold
Name side effets : Opoids (5)
- constipation [no tolerance]
- nausea
- sedation
- urinary retention
- neurotoxicity
Describe Neurotoxicity of opioids
increased opioids, no improvement, hyperesthesia or hyperalgesia, tactile hallucinations, allodynia, myoclonus, seizures, delirium
Describe : Fentanyl patch
- (Fentanyl transdermal = 200:1 morphine PO)
- Half-dose if cover skin with tegaderm underneath (do not cut)
- 12h before onset and 12h coverage after removal
- Consider inhaled ICS sprayed on patch for irritation
Describe management of constipation in palliative care (5)
- Scheduled toileting, sitting position
- Exercise/mobility
- Hydration
- Laxatives : (1) Osmotic (PEG), (2) Stimulant (senna, bisacodyl), (3) Surfactant/Lubricating (docusate, glycerine suppository)
- Warm water enema
Describe management of diarrhea in palliative care (3)
- Rehydration, electrolyte correction
- Hold laxatives
- Consider psyllium, loperamide, opioid
Describe management of no-vo in palliative care (3)
- Treat reversible causes
- Non-pharmacological management
- Pharmacological
Name reversable causes of no-vo (5)
- Severe pain, Cough, Infection, Hypercalcemia, Tense ascites, Raised ICP, Anxiety
- Drug-induced or metabolic
- Constipation / Intestinal obstruction
- Gastritis
- Oral candidiasis
Describe tx of Drug-induced or metabolic no-vo (6)
- Opioid rotation
- Haloperidol
- Metoclopramide
- Cyclizine
- Hyoscine hydrobromide
- Ondansetron
Name Non-pharmacological management of no-vo ()
- Cut out intolerant foods
- Control malodour
- Restrict intake (sips, ice chips, then gradually fluids to solids)
- Small frequent meals
- Cool fizzy drinks
- Avoid lying flat after eating
- Acupuncture/acupressure, ginger, relaxation, hypnosis, music therapy
Name pharmacological management of no-vo (6)
- Prokinetic (metoclopramide)
- 5HT3 antagonists (ondansetron)
- Antihistamine (dimenhydramine)
- Anticholinergics (scopolamine)
- Antipsychotics (Haloperidol 0.5mg SC q6-8h PRN, chlorpromazine, olanzapine)
- Cannabinoids
Describe management of Anorexia/Cachexia in palliative care (4)
- Rule out contributing causes (N/V, anxiety, pain, stool)
- Encourage favorite foods
- Small frequent meals
- Medical management:
Describe MEDICAL management of Anorexia/Cachexia in palliative care (4)
- Steroids (eg. dexamethasone 4mg PO BID at breakfast, and lunch), rapid onset but short-lasting (weeks)
- Progesterone (megestrol acetate), slow-onset 2-3 weeks for effect
- Prokinetic (metoclopramide) if early satiety
- Mirtazapine
Describe management of Asthenia/Fatigue in palliative care (4)
- Coordinate activities/help
- Change medications
- Sleep
- Medical management: Steroids. Methamphetamines
Describe management of Noisy respiratory secretions
in palliative care (3)
- Turn head to side
- Avoid deep suctioning
- Medical management : Glycopyrrolate, Scopolamine Atropine ophtalmic drops
Describe management of Confusion/delirium
in palliative care (3)
- Haloperidol PRN
- Methotrimeprazine PRN
- Midazolam PRN
Describe management of DEPRESSION
in palliative care (3)
- Psychotherapy
- Methylphenidate in short-term
- Consider SSRI if >4w
Describe management of ANXIETY
in palliative care (2)
- Hypnosis
- Benzodiazepines (lorazepam 1mg SL/SC q6h PRN)
Describe management of SOCIAL
in palliative care (3)
- Guardianship
- Wills
- Finances
Describe management of SPIRITUAL
in palliative care (3)
- Personal values : “Are spirituality or religion important in your life?”, “Are you at peace?”
- Relationships
- Meaning of life/death : “Why me?”, “What’s after death?”
Describe : Advance Care Planning and Goals of Care (7)
- Breaking Bad News
- Prognostication PPS
- Hopes and Fears
- Mandate
- Goals of Care : Treatments, resuscitation (CPR, intubation, ICU), antibiotics, PEG/NG feeding, palliative sedation
- Home vs. hospital vs. hospice
- Medical Aid in Dying
How to Prepare family for end of life (4)
- Progressive unresponsiveness
- Purposeless movements, facial expressions
- Noisy breathing
- Possible acute events and action plan (seizure, stroke)
How to confirm and document Pronouncement of Death (7)
- Check ID bracelet
- No spontaneous respiration
- No response to tactile stimulation and pain (pressure on nailbed)
- Absent breath sounds, heart sounds
- Absent carotid pulse
- Fixed pupils, non-reactive to light
- Time of death
